VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Young Men's Christian Association of Greater Richmond - Lakemont
51 Gibbons Avenue
Petersburg, VA 23803
(804) 861-0155

Current Inspector: Jennifer Moore (540) 430-0384

Inspection Date: Dec. 6, 2022

Complaint Related: No

Areas Reviewed:

8VAC20-780 Administration. 8VAC20-780 Staff Qualifications and Training. 8VAC20-780 Physical Plant. 8VAC20-780 Staffing and Supervision. 8VAC20-780 Programs. 8VAC20-780 Special Care Provisions and Emergencies. 8VAC20-780 Special Services. 8VAC20-820 THE LICENSE. 8VAC20-820 THE LICENSING PROCESS. 8VAC20-770 Background Checks (8VAC20-770) 20 Access to minors records 22.1 Background Checks Code, Carbon Monoxide 22.1 Early Childhood Care and Education

Comments:

An unannounced monitoring inspection was initiated on 12/6/2022 and concluded on 12/8/2022. The inspector was on site on 12/6/2022 from approximately 4:00 pm-4:55 pm. There were 8 children present, ranging in ages from 5 to 8 years, with 3 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, special care and emergencies, nutrition and background checks. A total of 5 child records and 4 staff records were reviewed. Staff records were reviewed remotely on 12/7/2022. Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return it to me within 5 business days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word corrected is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measures. Please do not use staff names; list staff by positions only.

Violations:

Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of four (4) staff records and interview, the center did not ensure to obtain a central registry finding by the end of the 30th day of employment for one (1) staff as required. Evidence: 1. The record of staff #3 (date of employment: 10/28/2022) did not contain a central registry finding. 2. Administration acknowledged that the finding was not obtained within 30 days of employment.
Plan of Correction:	We have talked through this process and added extra steps to make sure this doesn't occur again. This CRS has been sent out.
Standard #:	8VAC20-780-130-A
Description:	Based on a review of five (5) children's records and interview, the center did not ensure to obtain documentation that two (2) children had received the immunizations required by the State Board of Health before the first date of attendance as required. Evidence: 1. The record of child #1 (date of attendance: 11/2/2022) did not contain an immunization record. The record of child #4 (date of attendance: 10/17/2022) contained an immunization record dated 10/18/2022. 2. Administration acknowledged that the immunization records were not obtained prior to the first date of attendance.
Plan of Correction:	We have reached out to the parents to obtain all required documents.
Standard #:	8VAC20-780-140-A
Description:	Based on a review of five (5) children's records and interview, the center did not ensure that one (1) child had a physical examination by or under the direction of a physician: before the child's attendance or within 30 days after the first day of attendance as required. Evidence: 1. The record of child #1 (date of attendance: 11/2/2022) did not contain a physical record. 2. Administration acknowledged that the record had not been obtained.
Plan of Correction:	We have reached out to make sure we receive all items.
Standard #:	8VAC20-780-60-A
Description:	Based on a review of five (5) children's records and interview, the center did not ensure that three (3) records contained the required information. Evidence: 1. The record of child #1 (date of enrollment: 11/2/2022) was missing one (1) of two (2) required emergency contacts. Children's records are required to contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached. The record of child #2 (date of enrollment 10/11/2022) contained two (2) emergency contacts that were missing full addresses. The record of child #4 (date of enrollment: 10/17/2022) was missing two (2) emergency contacts. 2. Administration acknowledged that the emergency contact information was incomplete in the three (3) records.
Plan of Correction:	We are actively working on fixing these items and making sure we check all items before a child begins.
Standard #:	8VAC20-780-70
Description:	Based on a review of four (4) staff records and interview, the center did not ensure that the required staff information to be kept at the center was available for three (3) staff. Evidence: 1. The record(s) of staff #1 (date of employment: 2/14/2022), staff #2 (date of employment: 9/14/2022) and staff #3 (date of employment: 10/28/2022) did not contain the name, address, and telephone number of a person to be notified in an emergency which shall be kept at the center. The records did not contain Information, to be kept at the center, about any health problems that may interfere with fulfilling the job responsibilities. 2. Administration acknowledged that the required staff information was not available on site during the inspection.
Plan of Correction:	We have sent staff information sheets to the site.